Solve the Case

Poison,Reynold's or a Broken Heart
Charles Ayanleke MD,MRCPI

65 yo AAM nursing home resident with PMH of HTN,DM,CHF(EF 10-15%),COPD and OSA admitted 2 months ago with COPD exacerbation and an incidental finding of mediastinal mass on CXR confirmed on CT.

During that previous admission,he underwent a Video assisted thoracoscopy(VATS) and biopsy which confirmed a benign thymolipoma.A small left pleural effusion was also noted at the time but was not pursued.

He drank ETOH only socially and denies IVDU. He has a 40 pack years history of tobacco use.
He was readmitted 3 weeks ago to ICU with a lower abdominal pain diarrhea and fever,postive stool for C-Diff and evidence of extensive colitis from the sigmoid to the splenic flexure on Abdominal CT scan.C-Diff colitis was managed with Vancomycin (par PEG and enemas) and with Flagyl IV.

He went into septic shock and grew GNB in urine,subsequently treated with Zosyn for UTI.He had hypokalemia and refractory hypophosphatemia which were aggressively replaced. EGDT was commenced for septic shock but pressor support could not be withdrawn for days.A subsequent cosyntropin stimulation test came back positive and he was placed on Hydrocortisone and Fludrocortisone.

He stabilized and was transfered to the regular nursing floor after 8 days in ICU.2 days after the transfer,the rapid response squad was called for a sudden chest pain and he was found to have an NSTEMI with troponins of 7.3.He was transfered back to ICU where conservative medical therapy was instituted with Argatroban,plavix and apirin as he had documented allergy to Heparin(??HITT) although the actual nature of the allergy was unclear.Cardiology later changed argatroban to Fondaparinux S/Q for hospital formulary and cost reasons.

Pulmonary had postponed any thoracentencis until after the patient is off anticoagulation.

He gradually developed deepening scleral icterus and his bilirubin rose to >10mg/dl predominantly conjugated.ALP steadily topped 9,000 with only high normal transaminases but his GGT was >5000.
His ALP was normal in April 2008.
He had complained of a vague general abdominal pain worse over the Right upper quadrant.
An Abdominal U/S suggested coarse liver architecture consistent with cirrhosis without biliary dilatation. Repeat CT abdomen and pelvis was normal.
Antimitochondrial antibodies and hepatitis profile were negative.
He was deemed too unstable for liver biopsy(even the transjugular approach).He was put back on pressors after dropping his BP prior to a planned CRRT for worsening CHF and anaserca.

Gastroenterology discontinued any medication started within the last 2 weeks due to concerns of toxic/med-induced hepatitis.These include his Fondaparinux,plavix,aldactone and seroquel (which was started for anxiety and panic attacks).

He frequently became intermittently lethargic and required intermittent CPAP treatment for episodes of desaturation.

A day after his code was reviewed to DNRccA(as defined under Ohio laws),he went into cardio-respiratory arrest.CPR was not done and he subsequently expired.

Discussion:
The key differential diagnosis here include Ascending cholangitis,Cardiac cirrhosis and toxic or medication induced liver injury.The acuity of onset and the characteristic Reynold's pentad favors Ascending cholangitis in this very sick patient.
Unfortunately,he was too sick for a potentially life-saving biliary drainage via ERCP.
ERCP was the natural next step especially with the lack of biliary dilatation on Ultrasound scan in view of the very suggestive clinical picture.
MRCP may have helped establish a diagnosis but will not enable a therapeutic drainage procedure.He however received appropriate antibiotic cover with Piperacillin-Tazobactam.